What do Pakistani women know about New Zealand’s healthcare system?

Keywords: children, emergency/after‐hours services, Healthcare system, immigrant, New Zealand, resources, survey, women.

Research in other countries has shown that a lack of relevant healthcare resources for new immigrants may mean they end up with costly medical care services, as it is hard for them to find appropriate and subsidised care.^1–4 This problem may worsen when most immigrants come from low-income countries and are less able to access healthcare services for chronic diseases or mental health problems than the domestic population.^5,6 Rechel et al. have suggested that healthcare facilities should be available to all immigrants and relevant information provided, such as the location of medical centres and how to find them.⁷ International literature has also found that immigrant women encounter more barriers to accessing appropriate health care.^8–10

Each year, many immigrants arrive in New Zealand and face an unfamiliar healthcare system that they have to learn to navigate.¹¹ The number of Asian immigrants to New Zealand has grown rapidly during the last two decades. There are many reasons for this increase, such as seeking a better work–life balance, a smaller population, a better quality of life and quality of education for children.¹² According to the 2018 New Zealand population census, 6135 people from Pakistan live in New Zealand. Statistics also show that they are more highly educated than other Asian immigrants; for example, 21.6% have a Master’s degree compared to 7.4% of other Asian immigrants. Likewise, 3.7% have a PhD compared to only 0.9% of Asian immigrants.

This study aimed to explore the knowledge of Pakistani women immigrants about New Zealand’s healthcare system. It builds on an earlier interview-based pilot study that highlighted health information gaps and underutilisation of health services.¹³ The study objectives were: (i) to investigate Pakistani women immigrants’ knowledge about utilising the New Zealand healthcare system; (ii) to find out what information about the healthcare system they get from Immigration New Zealand and the Ministry of Health before and upon arrival in New Zealand; (iii) to determine who they ask for assistance for healthcare needs as new migrants; (iv) to determine their understanding of the ‘basics’, such as how to register with a general practitioner (GP), how to use emergency and after-hours services, how to find out about maternity services and subsidised care; and (v) to identify the challenges and hurdles they face while accessing the healthcare system.

A new questionnaire was developed, as no existing questionnaire suited the study objectives.¹⁴ The questions were designed to assess diverse aspects of the challenges new migrants might face when entering a new healthcare system and were trying to understand the basic information and demands of the system. A variety of question formats were included, such as yes/no, multiple-choice and open-ended questions. The survey was initially tested on 10 Pakistani immigrant women, and their feedback was used to improve it.

The population for this study were Pakistani women aged ≥18 years living in New Zealand for <5 years. The respondents were recruited through WhatsApp, Facebook groups, email, and text messages on Messenger.

The survey was managed through Qualtrics©, QualtricsTM. Respondents who clicked the survey link were directed toward the survey pages. The first page contained an information sheet with a brief description of the project, a consent form, and the time needed to complete it. The survey was in English, as most of the respondents during the pilot testing mentioned that they did not have Urdu or Urdu language keyboards on their phones to complete the survey. Being professionals, this group had a high level of English skills. The survey was circulated from 26 June 2019 to 15 August 2019. There was no koha for participation. Submitting a response was taken as consent to participate in the study.

The initial analysis of the data was conducted using Qualtrics©.

Ethics approval was obtained from the University of Otago Human Ethics Committee (Ref # D17/132).

By the end of the study, 202 respondents had clicked on the survey link and 200 respondents (99% participation rate, covering 881 family members) had agreed to participate. Only two respondents declined to participate in the survey. Ninety percent of respondents responded to all questions, and 10% of the respondents filled in 75%.

Table 1 presents demographic characteristics such as residence, number of children, age, profession, and annual household income. We also asked about immigration status; most respondents were on a permanent resident visa. And 22.5% had been in New Zealand for ≤1 year, 32.5% for 2 years, 27% for 3 years, and 18% for 4 years.

Table 1.  Demographic characteristics of survey respondents.

Ninety-one percent of the 188 respondents responded ‘no’ when asked whether they knew anything about the New Zealand healthcare system before arrival. The 16 responding ‘yes’ were asked what they knew, with 15 knowing about subsidised pregnancy care and free medical treatment for residents’ children.

Of the 188 respondents, 84% said they did not receive any information about the healthcare system when they reached New Zealand. The information received was about registration with a GP, free health care for children, and subsidised care for residents.

In our initial study,¹³ we found that participants used the term ‘register’ when referring to enrolling with a general practice, so this is the term we used in the survey. When asked who guided them to register with a GP, out of 185 respondents, 56% (n = 104) of them stated friends and relatives, and 20% (n = 37) said that the nearby medical centres played an essential role in getting them registered. Most surprising was that none of the respondents claimed that Immigration New Zealand helped them. Twenty-four percent (n = 44) stated that Google helped them get registered with a GP. The pattern of responses was similar in each city.

The most critical factor that influenced respondents’ decision when choosing a GP was the medical centre’s location. The respondent could pick more than one option in this question so that the total percentage could be more than 100%. Of 189 respondents, 82% chose the location as an important factor, 16% mentioned cost, and 11% chose ‘other’ factors. Only 4% of the respondents thought about language, which most likely reflects that all the respondents were well educated and did not find it a barrier to speaking English.

When respondents were questioned about whether they knew how to use a hospital’s emergency department and after-hours services during their early days in New Zealand, out of 180 respondents, 53% (n = 96) responded ‘No’, whereas 47% (n = 84) responded ‘Yes’.

When asked about their satisfaction with emergency/after-hours services, 80% (144/180) of respondents stated that they were not satisfied, and 20% (n = 36) were satisfied. Those not satisfied were asked to describe the reasons. Most of these respondents (n = 130) described in detail the reasons for their dissatisfaction. The waiting time at both was often too long, whereas after-hours services were also costly. Many reported that sometimes their children are so sick that it is hard to wait so long, and it should not take so long because it is an emergency.

Of the 186 people who replied to the question about the time taken to get acquainted with the New Zealand healthcare system, about 6% (n = 11) of the respondents said that it took 6 months, 12% (n = 22) said 1 year, whereas 52% (n = 97) stated it took >2 years. Thirty percent (n = 56) said they still do not know much about the New Zealand healthcare system.

When asked about the subsidised health care available, of the 180 people who answered this question, 84% (n = 151) said they were not aware of any, and 16% (n = 29) stated they were aware of healthcare subsidies available. In response to an open-ended question, those who did know about subsidies mentioned the community service card, free maternity services, free medical and dental treatment for children, and subsidised medicines for residents. There did not seem to be a link between time in New Zealand and knowledge of subsidies. Most of the women in our sample had been in New Zealand for 2–3 years and stated that they were still not aware of subsidies.

Respondents were asked if they still needed any New Zealand healthcare system information. Of the 189 people who responded to this question, 87% (n = 165) said they did. In response to an open-ended question, more information was needed on a wide range of topics, including: subsidies available for them and their children; disabilities; adult medicine and treatments; how to contact a specialist; counselling services; pregnancy; maternity care and services; how to find a midwife; and mental health.

When the respondents were asked about the most important information all immigrants should receive immediately on their arrival in New Zealand, 180 responded. One hundred and thirty-five respondents made suggestions about information that should be provided on arrival in New Zealand. Common suggestions were: how to get registered with a GP; health care for children; disability support for children; maternity services and antenatal classes; mental health for children; mental health during maternity; subsidised treatments; immunisation and vaccination for children; and the phone numbers for health help/advice lines. Being parents, they felt they faced hurdles and sometimes had to pay more due to a lack of awareness of the system.

When asked whether they found any useful healthcare-related information on the Immigration New Zealand and Ministry of Health websites, 76% (n = 138) of respondents said they did not find any useful healthcare-related information on their websites or had not checked. Twenty-four percent (n = 44) had found the websites useful, and 20 respondents described the information they obtained. This included information about maternity services and subsidies, immunisation, health care for children, and a healthcare helpline. However, some of the respondents stated that they did not know about these websites and had never visited them.

A total of 184 respondents responded to this question, and 76% (n = 140) of the survey population said they were satisfied with the overall New Zealand healthcare system. However, 24% (n = 44) said they were not satisfied. Thirty respondents provided reasons for their dissatisfaction. Most reported that health care is costly, and diagnosis is very slow in New Zealand. In addition, some of the respondents perceived that the GPs were not competent and used the internet for diagnosis in front of them.

When the respondents were asked whether there is a need for an introductory programme for new immigrants related to New Zealand healthcare information, 94% (n = 188) of the 200 respondents agreed. Only 6% (n = 12) of respondents thought there was no need for such a programme.

One hundred and ninety-four respondents answered the ‘tick all that apply’ question about the best ways to introduce an introductory healthcare programme. One hundred and fifty-six (80%) respondents chose online resources, whereas 30 (15%) favoured community education/workshops, and 44 (23%) said brochures/pamphlets would work for them. The majority of the respondents from each city considered online resources suitable for New Zealand healthcare system information. Most of the respondents new to New Zealand (<2 years) thought that a workshop would be a good option to access information.

Out of 180 respondents, 57% (n = 103) said there is no need for brochure/pamphlets to be in Urdu; however, 43% (n = 77) of the respondents responded that they would like to have an Urdu brochure/pamphlets. The majority of people from Wellington and Christchurch were looking for information in Urdu. The data were further analysed based on the time spent in New Zealand. The results indicated that most of the mothers who requested information in Urdu had migrated to New Zealand within the last year.

In this study, most respondents specified that they did not receive any information from Immigration New Zealand or employers before or after their arrival. They had to look elsewhere for information from Google, friends, colleagues, or relatives to help them navigate their new healthcare system. When searching Google for healthcare services, they were often directed to the official webpages, but the information available on the webpage was very limited. As many international studies have found, inadequate information about the healthcare system can significantly affect access and cause underutilisation of appropriate healthcare services.^15–18 Other studies have also found that inadequate healthcare knowledge resulted in more emergency visits and high costs.^19–21 Being new in New Zealand, not having a permanent address, and being unaware of the importance of registration with a GP, most of our respondents reported that they were not satisfied with their care from after-hours or emergency providers.

Most respondents reported that it took >2 years to get familiar with the New Zealand healthcare system, which is in line with our earlier findings.^13,22 We had a diverse sample of respondents regarding how long they had been in New Zealand. The results suggest that healthcare information may not increase immensely over the first 5 years spent in New Zealand. Most (87%) respondents think they need more information because not much information was available on the Immigration New Zealand and Ministry of Health webpages. Therefore, we recommend that information related to the healthcare system, resources and available healthcare subsidies be provided within the first year of their arrival. Mehta conducted interviews with 12 healthcare service providers across Auckland to understand the needs of Asian communities and identified many barriers to health care, including the lack of knowledge of the New Zealand health system.²³

Tamanam found that South Asian respondents in New Zealand use social connections to obtain the required health information.²⁴ For South Asian immigrants, using social connections and support is a leading strategy for the navigation of health care. Different South Asian community groups and associations are sources of information where South Asian immigrants connect and obtain information for settlement.²⁴ Ahmad et al. studied health promotion approaches among Chinese and South Asian women residing in Canada. The study does contradict some of the results of our study. Similarly, it emphasises the need for community-specific development of health promotion programmes for effective health promotion when targeting underserved communities.²⁵

Future health promotion interventions need to address targeted communities’ sociocultural and day-to-day life contexts.²⁵ In our study, information on the Immigration New Zealand and Ministry of Health webpages was not considered relevant and sufficient by respondents, even when they were looking for necessary information such as after-hours services, medical centres, eligibility for public health, and dental care. Some of the respondents mentioned that they had never visited those websites. More than half (66%) reported that the information provided by Immigration New Zealand and the Ministry of Health was not helpful. It was mainly related to the type of visa rather than for all immigrants. For example, information was available for someone on a 1-year work visa who is not eligible for public-funded healthcare services such as free maternity care or free medical treatment for children. Almost all respondents favoured an introductory programme about New Zealand’s healthcare system for recent Pakistani immigrant women. Most of the respondents provided detailed answers on the types of resources they want, such as registration with a GP, emergency services and support, maternity services, healthcare services for children, vaccination for children, health care funded by the government, mental health and disability services, and how to approach specialists. Ahmad et al. suggested that health literacy promotion and messages or programmes for South Asian women hold greater value and have a stronger influence on well-being and health when messages are customised to their specific needs and immigration experiences.²⁵

This is the first study to focus on Pakistani immigrants’ experiences and knowledge of New Zealand’s healthcare system, and highlights that even highly educated immigrants face considerable challenges. We tested the questionnaire on 10 Pakistani women and used their feedback to improve it. The limitations of the study include narrow inclusion criteria, as it only included women; therefore, results are difficult to generalise from the sample as it was not randomly selected. Although we attempted to disseminate the survey link widely, those who did not receive it or did not respond may differ from those who did.

In this study, we conducted a nationwide online survey. We found that newly immigrated Pakistani women face challenges with finding information about New Zealand’s healthcare system, which impacts accessing health care for themselves and their families. Information is particularly needed before or soon after arrival in New Zealand. Most of the new immigrants were looking for information (online/brochure) on finding a GP, registration with a medical centre, available subsidies for healthcare services, and medications and emergency/after-hours services. Due to their lack of healthcare information, they faced challenges with children and sometimes had to pay more for healthcare services.

Immigrants often struggle to learn how to navigate new healthcare systems. For equity in health care in New Zealand, the Ministry of Health and Immigration New Zealand should provide more healthcare resources in the New Zealand healthcare system information for new immigrants. Better knowledge will result in a better understanding and use of New Zealand’s healthcare system and, ultimately, better health outcomes. Further research on New Zealand’s immigrant minorities can address this gap and enhance the current literature on healthcare resources and health inequities.

The data can be obtained from the corresponding author upon reasonable request.

We have no conflicts of interest to disclose.

This research did not receive any specific funding.